Saturday, January 30, 2016

In my last post- Medications, Parrots, and Crazy Virginia Laws --, I talked about Robert Whitaker's post on Pete Earley's page. I put a link to Pete Earley's blog, but not my Shrink Rap post, up on my personal Facebook page. Now some of my Facebook friends are psychiatrists, so this turned my Facebook page into something of a blog post, with no cute animals. You followed all that, right? (It's some weird version of social media hell, and yes, I tweeted it as well). The commenters there gave me permission to put their responses as comments on Shrink Rap, but Dr. Mark Komrad's response exceeded the character count for a blog comment, so I'm giving him a guest post slot here. Dr. Komrad is the author of You Need Help! an excellent book on how to get a loved one into treatment. His response is below:------

I
think there are some emerging intellectual "cults" or "fetishes,”
maybe best called "overvalued ideas,” that are relevant to Whitaker’s
blog post. A major one now dominant in Medicine is “evidence based."
Not a bad concept, but an overvalued one. My experience as a
practicing clinician so often contradicts the evidence base. Can this
just come down to the dismissal of the clinical experience of a seasoned
clinician as invalid because of individual-bias? Should the wisdom of
clinical experience be trumped (wow- a word whose meaning is changing!)
by large statistical sets, or amalgamated statistical sets, as in
meta-analyses? That seems very much black-and-white thinking. There is a
dialectic between two different ways of knowing-- clinical experience
vs. the study of large sets of patients under controlled conditions. We
in psychiatry are familiar with many such dialectics: mind and brain,
nature and nurture, biology and psychology, form and content, autonomy
and paternalism, explanation and understanding, etc. See Philip Slavney,
"Psychiatric Polarities."

In
my own experience, I practice not too much differently from many other
psychiatrists, and not radically different from what Whitaker wants. In
schizophrenia, I follow "first break" research and go "low and slow."
Early in the course I attempt to taper off antipsychotics slowly. That
commonly fails, but not always. With long-term patients I have tried
time and again to lower doses to the lowest possible dose. I make tiny
changes over many months or even several years (yeah, I've been around
long enough, and my patients stay with me)-- slow enough to rule out
withdrawal effects. Yet time and again people end up eventually
relapsing, and we have to reverse course. With the majority of
patients, reversing course doesn't work, and a few have never returned
to their former (often excellent) baseline (prior to trying this
oh-so-cautious tapering). For many patients on maintenance meds, the
dose goes up, the dose goes down, as symptoms wax and wane-- like any
other chronic illness. Make no mistake, schizophrenia IS a chronic,
lifetime illness, and the chronicity is not CAUSED by meds, as ample
evidence suggests, from the pre-antipsychotic era. It seems very
compelling to me, from my 30 years of clinical experience in treating
schizophrenia, that these meds don't only have acute efficacy (like
antibiotics), but also prophylactic value, to minimize morbidity (like
Lipitor).

Of course, I cannot rule out the possibility that, as Whitaker suggests, long-term antipsychotic treatment might partially cause
the brittleness and dependency on meds for stability and remission.
That could account for my frequent experience of failed-tapers. It's a
good question for research. But it would take a few decades to be sure,
by following parallel cohorts of persistently medicated patients and
rarely medicated patients. Maybe enough time has passed in the
antipsychotic era that some valuable evidence is now just emerging. But
4-5 year studies wouldn't be enough time. It would need to be 20-30
years. Those are quite difficult (and expensive) studies to do. I
remember how expensive and complex it was to do the multi-center study
20 years ago that asked about maintenance meds in recurrent depression
after patients get well-- can you stop, lower the dose, or should you
sustain the same dose it took to achieve remission? (answer: the third).
Many millions $, 20 centers, and that was only 5 years.

I
have shared the ambiguity of treatment choices, based on some of these
studies, with some of my patients and families. It is, however, RARE
that a patient who is doing well wants to take a chance. The
overwhelming response has been, "if it's not broken, don't fix it." In
patients that are doing well, with the current state of evidence, it's
hard to ethically justify tapering them off antipsychotics entirely.
Even patients doing poorly have done WORSE when meds are stopped. Maybe,
EVENTUALLY they might do better, these studies suggest, but until then,
their increased morbidity off meds, even temporarily (months, years),
will be extremely bad for their lives, the lives of others, and even
their very survival.

Maybe
25 years from now there will be enough evidence and new EXPERIENCE by
clinicians who have started early in the onset of schizophrenia to use
more temporary courses of antipsychotics. Then, maybe clinical
experience will corroborate some of these very preliminary studies. That
might enable the power of more statistical studies to be complemented
by the equally valuable power of clinical experience. As is typical, in
the evolution of Medicine, the dialectic of these two ways of knowing
will result in the synthesis of changing treatment approaches. By then,
though, we may have entirely new and different inventions for treating
schizophrenia!

Friday, January 29, 2016

For today's post, I'd like to send you around the web.First, Pete Earley has a piece up by Robert Whitaker of Mad in America. Whitaker clarifies his position on antipsychotic medications and how their use should be avoided or minimizedin Robert Whitaker Explains his Research after being Pigeon-holed as Anti-Medication. Let me add my bias: I didn't like Whitaker's book Anatomy of an Epidemic where he concluded that anti-psychotics cause psychiatric disability. His point was correlational -- as anti-psychotic use went up, so did SSDI (government disability) claims. It's not that easy -- there are other factors that contribute to disability claims including financial & social incentives and the acceptability of being on SSDI. After you read the post on Pete's blog, I'd like to make two points:

~I don't think that it's controversial that people should be on the lowest possible dose of medications --any medications. Unfortunately, in psychiatry, we figure out the lowest dose by dropping the medications until someone gets sick. It's not benign, with each small drop in dose there is some risk that a person will end up psychotic, in the hospital, or unable to function, and recovery can take months or more. So when someone is doing well, working and involved in meaningful relationships, it's not a low risk issue to drop medications. If they are having side effects, it's a lot easier to take this risk, because at least you're addressing a problem. This stuff is not easy when you're talking about real people.

~I remember life before the second generation antipsychotics. Patients hated taking Haldol and Prolixin and Mellaril and Stelazine. They were very articulate about how miserable the side effects were, and I don't recall anyone saying that patients wouldn't take Haldol because they had "anosognosia" (ah, we didn't have that word then). Psychiatrists were well aware that patients didn't take the medications because they made them feel like molasses had been poured into the crevices of their brains, or worse. Second generation antipsychotics may be no more effective, but they are more acceptable to many patients.

Having said all that, Whitaker may be right that people do better with less medicine, either because those who aren't as sick don't need as much medicine and may be able to completely stop, or because the medications sensitize people and make them worse (I have no answers here.) When someone is psychotic and suffering, this isn't all that helpful. I wish we had better answers. Whitaker, and others point to Open Dialogue as a panacea, and it may be a better way with better results -- not much of it is controversial, just expensive and it requires resources for immediate response that we don't seem to have in this country. There are 5.5 million people in Finland and 321 million people in the US, so the issues are different, and people in Finland get hospitalized and disabled, too. While I'm pointing you around, Alex Langford does a nice job of discussing Open Dialogue with all it's pros and cons on his blog Here. Well worth the read. ---------------You've heard of Creigh Deeds? He's a Virginia state senator whose very ill and very dangerous son was released from an ER because of a quirk of Virginia state law that said if a bed could not be found within 6 hours, then a patient must be released. Tragedy ensued -- Gus Deeds repeatedly stabbed his father and then died of suicide. Over on Clinical Psychiatry News, I explain the idiosyncrasies of Virginia law that could allow such horrors to happen. See Understanding the Deeds Family Tragedy.----------------And for the latest news in schizophrenia research, here's a study in Nature that's making headlines everywhere. If I could understand it, I'd explain it to you. Maybe Roy could drop by for this one? We haven't seen him for a bit.----Lastly, I'll include a link to an article about PTSD and parrots. ClinkShrink likes birds, and she loves parrot jokes, so please do share yours. What Does a Parrot Know About PTSD?

Thursday, January 21, 2016

Dr. Michael I. Bennett had a opinionator piece in the New York Times a few days ago that made my blood boil. In You Are Stronger Than You (And Your Therapist) Think, Bennett talks about a patient who has been in weekly psychotherapy for years until the insurance company decides that the patient does not need weekly sessions -- 12 sessions per year are approved. But the patient is not Bennett's patient, and he writes from the perspective of someone who has worked for an insurance companies. Bennett writes:

I know what it’s like,
as a psychiatrist, to feel that your patient’s safety depends on your
availability to provide emotional support. However, I also know from
experience that patients usually survive our vacations, unavoidable
short-notice absences and cellphone failures without actually falling
apart. Certain patients feel very vulnerable, needy and worried about
abandonment, but they feel that way long before we start treatment and,
usually, those feelings don’t change in response to treatment.
Objectively, there’s little evidence that the treatment relationship is
as healing, powerful or anchoring as we and our patients wish it would
be, or as we experience it to be.

If weekly therapy
does, indeed, have only a limited potential to heal and protect, then
our patients must be stronger than they, and we, think they are. We know
that depression and anxiety routinely distort our ability to think
realistically by making us see nothing but our faults, failures and
worst-case scenarios. When we’re sure that things will fall apart if
weekly treatment isn’t readily available, we may well be accepting and
stoking this distortion and, inadvertently, helping our patients believe
that they are as weak and helpless as they feel.

Depression and anxiety, Bennett explains, can make some people feel like they can never be strong. He goes on to advice:

My advice to my colleague was to make a list of the patient’s strengths
and encourage her to review what she had learned from the tough
experiences that she had endured and survived. It would be normal for
her to fear the worst from the coming transition in treatment, but this
was also an opportunity for her to see through the negative distortion
caused by that fear, review her resources and prepare plans for managing
whatever worst case scenarios she could imagine. My colleague could
assure her, of course, that emergency care was available. But he could
also express confidence in her ability to use what she had learned in
their work together to survive and thrive, in spite of her doubts and
fears — and of his.

Where, oh where, to begin. To contain my urge to rant and ramble, I'll hold my analysis to a few bullet points:

Obviously, Bennett may be right that therapy may foster dependence. The therapist may be financially motivated to patients coming frequently, and there are patients who could be seen less often then they are.

So how do we determine how often a patient should come? The therapist & patient in this case say weekly; the insurance company says monthly. Why 12 appointments? Why not 11 or 13? Or 17? Or 9?

What is the goal here? Is it to find that absolute minimum number of appointments that the patient can tolerate without another serious suicide attempt (as this patient had)? Without hospitalization? With medication? Without a recurrence of symptoms? (Which Symptoms?)

Is dependence bad? What if one hour a week of "dependence" and any accidental psychotherapeutic work that happens to happen along with that dependence comes with the the trade-off is able to live life more fully and productively?

"Objectively, there’s little evidence that the treatment relationship is
as healing, powerful or anchoring as we and our patients wish it would
be, or as we experience it to be." Excuse me??? Oddly enough, it seems to me that the therapeutic relationship is often quite helpful.

Might I add that very few patients continue for an extended period in weekly psychotherapy -- it's expensive (even with insurance there are deductibles and co-pays), and time consuming. There is some automatic self-selection here that leaves the most vulnerable and distressed of people who even want this.

Okay, so what do we think about someone from an insurance company who has never met a patient, and generally hasn't reviewed their history and medical record, should determine how much treatment they need? Oh wait, managed care has been around for a while. Now whose idea was that?

Amid
a conversation about student retention this fall, the president of
Mount St. Mary’s University told some professors that they need to stop
thinking of freshmen as “cuddly bunnies,” and said: “You just have to
drown the bunnies … put a Glock to their heads.”

Simon Newman was quoted in the campus newspaper, The Mountain Echo, on Tuesday,
in a special edition that reported the university’s president had
pushed a plan to improve retention rates by dismissing 20 to 25 freshmen
judged unlikely to succeed early in the academic year. Removing
students who are more likely to drop out could hypothetically lead to an
improvement in a school’s federal retention data; the deadline for
submitting enrollment data is in late September.

Newman, a
private-equity chief executive officer and entrepreneur who was
appointed president of the private university in Emmitsburg, Md., in
2015, said Tuesday that there are some accurate facts in the Echo story,
but “the overall tone of the thing is highly inaccurate.”

Oy. I don't know what President Newman's issue is that he talks about drowning and shooting bunnies, but I since I don't know him --and would like to keep it that way-- I'm going to refrain from commenting on the judgment of the president of a religious educational institution who uses such harsh, violent, and vivid metaphors for talking about those he's entrusted to educate. So I'm not sure this is a psychiatric issue, but I want to comment on the wisdom of weeding out freshmen who are doing poorly in their first month of college. If one could tell within weeks of their arrival on campus who is definitely not going to make it to graduation, then I would agree with Dr. Newman's concept, but let me use my own language. If you know for sure that someone is not going to be able to graduate from college, then you would do them the kindest service by not accepting them into your university to begin with. If you did make a mistake and accept someone who obviously cannot succeed, then it may be best to help them exit early. College is not for everyone, and if you're never going to graduate, then it may be better to forgo the expense, the debt, the years of struggle and discouragement, the lost income and lost opportunities to master other skills. Of course, this could be wrong; someone who never graduates may learn incredibly useful things -- both in classes and in the struggle-- and may form invaluable friendships and networks. Bill Gates didn't graduate from Harvard. Steve Jobs dropped out of Reed. They did okay without the sheepskin.

Even if it's not all about the diploma, the fact is that the first semester of college is a very stressful time. Teenagers are leaving home for the first time, they have to wake up and get to class without alarm-clock Mom, perhaps after late nights up using their newfound freedom to discover substances or the opposite sex. They may not have a sense of how much they need to study, and some may be up far too late pounding at the books, or simply worrying. Others have to work to get all the bills paid, and figuring out the work/college/social aspects of school may be quite hard. Some college freshmen get homesick. Some become ill with serious psychiatric disorders. But even the smartest, healthiest, and most driven of students may struggle that first semester in college. Since college is about educating people, it does seem that some tolerance of these difficulties is needed. From what I can tell, the predictive value of that first semester is not terribly good. I've heard stories of kids who've had any number of issues and terrible grades, who have then gone on to do well. It may not have been a smooth ride, but it was one that got finished.

I vote for coddling the bunnies for a while, at least while they get through the transition of separating from their families and figuring out their new environments and its demands. And you know, I don't think glocks are the answer to very much, and I'm all for a kinder, gentler world.

Monday, January 11, 2016

On January 8th, Bloomberg Business ran an article on how law students are reluctant to get treatment for psychiatric problems and for addictions. It's not that law students don't suffer from these problems; in fact, surveys show they do in significant and increasing numbers. Natalie Kitro writes:

People preferred to leave their illnesses untreated than risk
not becoming a lawyer. More than 60 percent of students said they didn’t
get help for their reliance on drugs or alcohol because they were
worried it would affect their career prospects or their chances of
getting admitted to the bar. Before they can practice law, students have
to pass a “character and fitness” screening, in which officials look
into their personal histories with the aim of rooting out people who are
too morally compromised to serve clients. The American Bar Association says potential red flags include “drug or alcohol dependency” and “mental or emotional instability.”Law
schools have tried in recent years to convey that students will not be
penalized for admitting that they’re suffering, but the report suggested
that the efforts haven’t gone far enough. It is tough to counter what
the study characterized as a deeply rooted culture of fear in legal
education that discourages students from admitting weakness.

So much for our legal colleagues. Today, Dr. Aaron Carroll has a compelling article in the New York Times about why doctors don't get help for psychiatric disorders. "In silence is the enemy for doctors who have depression," Carroll courageously starts by talking about his own episode of illness. Carroll notes:

Last month, a study
in the Journal of the American Medical Association reviewed all of the
literature on depression and depressive symptoms in resident physicians —
those are doctors still being trained. They found more than 50 studies
on the subject. Research shows that almost 30 percent of resident
physicians have either symptoms or a diagnosis of depression.

He goes on to postulate:

What
makes this all worse is that medicine is a profession in which
admitting a problem carries a stigma that can have more impact than in
others. A study published in 2008
surveyed physicians in Michigan, asking them about their work
experiences and if they had depressive symptoms. More than 11 percent
reported moderate to severe depression. About a quarter of them reported
knowing a doctor whose professional standing had been hurt by being
depressed.

Photo

Credit
Jody Barton

Physicians
with moderate to severe depression had a decrease in work productivity
and job satisfaction. They were also two to three times more likely to
say that they were worried about, or had difficulty getting, mental health care. Although the Americans With Disabilities Act,
passed in 1990, prohibits employers from asking broad questions about
illnesses when people apply for jobs, state medical licensing boards still ask specific questions about mental health.

Because of this, physicians are much more likely to avoid treatment. They’re also more likely to self-medicate.

Sometimes that medication is appropriate, as with anti-depressants. Often, it is not. A 2012 study in JAMA Surgery
found that more than 15 percent of the members of the American College
of Surgeons had a score on a screening test consistent with alcohol abuse
or dependence. Among female surgeons, the prevalence was more than 25
percent. Those who were depressed were significantly more likely to
abuse or be dependent on alcohol.

And if that's not enough, two weeks ago, KevinMD ran an article called "Don't poop wher you eat: Mental Health Services for Young Physicians". Amy Ho talked about insurance requirements that residents in training often must get health care --including mental health care -- at the institutions where they work. Ho talks about the 29% of residents who are depressed, and the reality of seeking mental health care at an institution where you work:

While privacy protection acts like HIPAA are real, they are difficult
to trust when you know every single one of your co-workers and
ancillary staff (nurses, attendings, etc.) have a password into your
private file. Further, unrelated medical care (for example, an ER visit
during work hours from a needle-stick accident) allows completely
HIPAA-compliant access by one of your coworkers into all of your
records.There is a saying, “Don’t [poop] where you eat” — that is, to keep
personal and professional separate. For many residents whose health care
is limited only to their place of work, there are often no other
options. Of depressed first-year residents, over half cited “perceived lack of confidentiality” as a barrier to treatment.

So I'd like to suggest that these issues of stigma have gotten worse, and not better. When I was a medical student at an institution with a strong psychoanalytic bent, entering psychotherapy was considered part of what one did to get to know yourself better: essential if you were going to be a psychiatrist, but also not shameful if you believed the unexamined life was not worth living. People talked openly about being in therapy. The chief resident in psychiatry put his analysis schedule on the unit bulletin board (times not to disturb him). A cardiologist told me he wanted to be a psychiatrist until he went into treatment and realized he only wanted to deal with his own issues. People openly talked about going to therapy. One of my classmates had a very serious suicide attempts -- it wasn't widely known, but I asked her roommate where she was headed one evening and the answer was to visit her in the ICU where she was on a ventilator. I don't know what transpired from there, but I do know she wasn't kicked out of medical school--as she might have been today-- and she went on to graduate on time and to obtain a very competitive residency slot. It's not that it was such an ideal world -- many people at my undergraduate school died of suicide and I don't know if those people were in treatment or not. But in some circles, there was less concern with secrecy and stigma. I believe that certain behaviors have always been, and always will be, stigmatized. When your mental illness leaves you to suffer quietly, the problem is yours, and if we hadn't come to associate "mental illness" with mass murder, and the possibility of unpredictable, disruptive behaviors, if we didn't erode privacy with records in the cloud, and if we didn't make it so damn difficult and expensive to get good treatment, then there should be no shame for seeking treatment for depression, anxiety, or even most substance abuse problems. I'm not sure our society has ever been comfortable around florid psychosis, nor do I think it ever will be. Okay, hold with me for one more article. In yesterday's Washington Post there was the story of the Dallas District Attorney who's position was being threatened because she disappeared for a couple of months to get inpatient treatment for depression, and had been treated for substance abuse. But this DA's illness was, per the media, not just about her own personal suffering. In a paranoid state, she fired colleagues, she was obviously intoxicated at work, and her illness left her impaired and made life difficult for others, until she got treatment and recovered. A judge dismissed a lawsuit to oust her. I wish her all the best moving forward. One might hope, however, that people in such powerful positions might feel it's safe to get help before their problems effect others.

Tuesday, January 05, 2016

We talk about mental illness based upon a standardized set of symptoms, where the symptoms co-occur in groups/clusters/syndromes in ways that enable us to cluster them together (i.e. make a diagnosis), treat the illness we've defined, and have some means of predicting outcome (i.e. 90% of people will have full remission of their symptoms within 6 months). We talk about these clusters of symptoms as being illnesses or disorders, and we look for biological correlates -- changes in brain chemistry, anatomy, metabolism -- to divide those people who have the disorder from those who don't in the hopes that someday we will have tests to tell us who will respond to various treatments. It would be very nice to get rid of all this trial and error medication cocktail stuff and just have a test that says "Meds won't work for you, you need TMS," or "no point in using an second generation antipsychotic, go straight to clozapine." So far, no great breakthroughs in terms of either diagnosis or treatment predictability, but give it time. So there was an article in the New York Times on January 2nd titled "Is the Drive for Success Making Our Children Sick?" Vicki Abeles talks about how childhood stresses lead to illnesses, including ulcers, as well as more medical illnesses as children age into adults.Abeles writes:

STUART
SLAVIN, a pediatrician and professor at the St. Louis University School
of Medicine, knows something about the impact of stress. After
uncovering alarming rates of anxiety and depression among his medical
students, Dr. Slavin and his colleagues remade the program: implementing
pass/fail grading in introductory classes, instituting a half-day off
every other week, and creating small learning groups to strengthen
connections among students. Over the course of six years, the students’
rates of depression and anxiety dropped considerably.

But
even Dr. Slavin seemed unprepared for the results of testing he did in
cooperation with Irvington High School in Fremont, Calif., a
once-working-class city that is increasingly in Silicon Valley’s orbit.
He had anonymously surveyed two-thirds of Irvington’s 2,100 students
last spring, using two standard measures, the Center for Epidemiologic
Studies Depression Scale and the State-Trait Anxiety Inventory. The
results were stunning: 54 percent of students showed moderate to severe
symptoms of depression. More alarming, 80 percent suffered moderate to
severe symptoms of anxiety.

“This
is so far beyond what you would typically see in an adolescent
population,” he told the school’s faculty at a meeting just before the
fall semester began. “It’s unprecedented.” Worse, those alarming figures
were probably an underestimation; some students had missed the survey
while taking Advanced Placement exams.

Okay, so wait, at least half of a group of students surveyed were moderately to severely depressed (?what about mildly depressed), and 80% were moderately to severely anxious? And the symtptoms abated when the stress disappeared? This doesn't make sense -- are our disorders illnesses --- brain diseases (as some like to call them)-- or are they part of the spectrum of normal reactions to stress, pressure, and likely lack of sleep?

In a clinical setting, I'll tell you that sometimes it feels really clear cut: there are people who get sick and they get severely psychotic, or they markedly change from their usual personality. They shut down and lose their usual vitality and ability to function; they aren't showing up for those AP exams. They become so symptomatic that they become someone totally different, and there is no 'hiding' their illness. In other cases, it's not so clear cut -- people come in complaining of symptoms of depression, loss of interest, sleep changes, libido changes, suicidal thoughts, and any mix of symptoms that meet criteria for a disorder, and they attribute their distress to a given set of life circumstances. But they're functioning in their usual roles, and they are able to mask their symptoms: the rest of the world may not know how badly they feel. If they are coming to see me as a psychiatrist, they often want medications, and medications often help. Would they need medications if we could remove the stress? Often they say 'yes' but we can't make that happen. Maybe you're thinking about school stress and pressure to achieve, but there are other stresses -- illnesses, financial burdens, divorce, family chaos -- which don't go away by dropping a class or giving up tuba.

If the studies cited above are accurate -- and I didn't look at them -- and the symptoms are persistent, then this doesn't fit with our idea of mental illness. It comes to be about a normal reaction to stress, a need -- as noted above-- to change our environment, and a question as to what gives resilience to those few who don't have symptoms.